Obesity Discrimination is Alive and Well, Just Ask Chris

Episode 31 of The Pound of Cure Weight Loss Podcast is titled, Obesity Discrimination is Alive and Well, Just Ask Chris. The title comes from our In the News segment where we talk about an article from The Maine Wire that examines a lawsuit filed against Cigna claiming that obesity is a disability and Cigna’s failure to cover GLP-1 medications constitutes discrimination based on disability. 

 In our Patient Story segment, we talk to Nikki. Though not a patient of ours, Nikki had a gastric bypass back when the procedure was done by opening up the stomach to operate. She also works for a great organization called Obesity Help. A lot has changed since her surgery and she is here to share her experience as well as talk about all the great things Obesity Help is doing for the bariatric community. 

 Reading the nutrition facts label can be confusing. This is not by accident. Big food companies have influenced the label design in order to confuse consumers into thinking foods are healthier than they actually are. So, in our Nutrition segment, Zoe offers some tips on how to navigate the nutrition facts label. 

 In our Economics of Obesity segment, we dive into the cost of obesity and whether or not it’s financially viable for insurance companies to cover expensive treatments like GLP-1 medications. 

 Finally, we answer 3 of our listeners questions including, what can be done to prevent gallstones after bariatric surgery, our thoughts on oats in almond milk, and whether or not taking GLP-1 medication before surgery increases postop weight loss.

 Here is the information referred to in the Patient Story:
 https://www.obesityhelp.com/events/tickets/ -Promo Code: POUNDOFCURE25 for $25 off through 7/7/24 

https://www.obesityhelp.com/events/speakers/ -More coming 

https://www.obesityhelp.com/events/hotel-accommodations-2/

https://www.facebook.com/events/s/bariatric-connect-2024-nationa/739412618351241/

https://www.obesityhelp.com/articles/2024-bariatric-connect-scholarship-tickets/

 nikkih@obesityhelp.com

Transcript

Dr. Weiner: 0:17

After 20 years of doing this, studying this, spending my entire life really dedicated to treating the disease of obesity and it's taken me 31 episodes for me to speak freely, zoe but Chris does not know what the he's talking about.

Zoe: 0:36

Okay, Welcome back friends. Here we are in the Pound of Cure Weight Loss Podcast, episode 31. Obesity discrimination is alive and well. Just ask Chris.

Dr. Weiner: 0:46

Yes, we're going to hear from Chris. Just a little hint. I'm not a huge fan of Chris. Yeah. Yeah, I mean not all Chris's. Yeah, there's one, chris, in particular. I don't know his last name, not going to lie. So, zoe, we've put together a bunch of before and after pictures in the office. I know you've been a big part of this, working with our patients to get their before and after pictures. So first of all, I want to give a shout out to our patients who have been generous enough to give us these before and after pictures. Sometimes, having some of those pictures out there, in public like that's.

Dr. Weiner: 1:21

That's putting yourself out there. So we really, really appreciate that. But I also know that it's so helpful, so we're putting these around our office so that anybody, when you come in for an appointment, you can see hey, this is this is what, what we're able to do. We've got GLP-1 patients, we've got surgery patients. I don't know if we have a nutrition patient up there, I don't know if we have a nutrition patient up there.

Zoe: 1:41

I don't know, but we've got one on the podcast coming up soon.

Dr. Weiner: 1:44

Oh, fantastic.

Zoe: 1:50

But my favorite part about these before and after posters is the QR code so that people can listen to their segment on the podcast, which I think is just so cool Sitting waiting for their appointment, listening to the patient's story and really being able to put a face and before and after to that story is just so powerful.

Dr. Weiner: 2:05

Yeah, so we've got those. So if you're coming into our office in the near future, please take a look at those, let us know what you think, and if you're one of our past patients who's really happy with their success, we would love to see your before and after pictures and we'd love for you to share those with us so that we can share them with others to help them make this decision for themselves.

Zoe: 2:25

Feel inspired and motivated.

Dr. Weiner: 2:27

Yeah for sure. All right. So our In the News segment comes from the main wire, main being the state, not the main thing. So this comes out of Maine, where there's a 29-year-old woman who filed a lawsuit against Cigna, her insurance company, claiming that obesity is a disability and that Cigna's failure to cover GLP-1 medications constitutes discrimination based on a disability. So she's leveraging the ADA, the American Disability Act, which essentially mandates that people with disabilities cannot be discriminated against. Now, first of all, the ADA does not specifically list obesity as a disability. So, all of a sudden, this lawsuit is a little bit of a stretch, because it's not like and there's all different types of disabilities. You can be disabled because you're depressed, because of mobility limitations, and there's a lot of different ways you can be disabled, but obesity is not one of them.

Zoe: 3:35

But obesity is a disease, and so maybe that's the distinction disability versus disease.

Dr. Weiner: 3:39

That's where they're going with this. That's where they're going with this. And obesity is a disease. I don't think that's really debatable at this point. But there are courts who have determined that you can be disabled from obesity. And having been a bariatric surgeon for almost 20 years now, I have seen plenty of patients who are disabled. I saw one actually just today. Patient is over 500 pounds, can barely walk. I mean, if he's not disabled, I don't know who is.

Dr. Weiner: 4:11

So anyway, they're suing for this and I think the first thing and really what kind of caught my attention when I looked at this article were some of the comments, and this is where our friend Chris comes in. So Chris says in the comment when they're talking about this woman suing for GLP-1 coverage, said I bet this sow sits on her fat ass in front of the TV every night eating her chips, soda and Twinkies and then blames everyone else for her being a fatso. No sense of responsibility for one's self and one's action. Nice use of the third person there, right? No drug will overcome a lack of willpower, as obesity is not a physical disease Too bad. There isn't a pill that makes you work your ass off. If there was, she wouldn't be suing for that. I just want to let that sit there for a second.

Zoe: 5:06

So it's kind of heavy.

Dr. Weiner: 5:07

Yeah, I mean the fact that this person took this time that's one sentence took the time to write this down, direct this at a person he has never met.

Zoe: 5:22

With so much anger.

Dr. Weiner: 5:23

So much anger, and I think these comments are everywhere. They're not hard to find when you see them. I think there's two things you need to know. The first is that this comment says so much more about Chris than it says about the woman who filed the lawsuit or anyone else suffering from obesity. This says that Chris is angry, probably feels slighted and thinks that he deserves more in life than he's gotten, and he feels better when he takes this out on someone else, when he takes this out on someone else. The second is after 20 years of doing this, studying this, spending my entire life really dedicated to treating the disease of obesity and it's taken me 31 episodes for me to speak freely, Zoe but Chris does not know what the he's talking about. This is not why people develop obesity.

Zoe: 6:22

We talk about that all the time.

Dr. Weiner: 6:23

Yeah, and I think this comment really goes directly against our basic tenets that we have as a practice in terms of, first of all, understanding that it's not a willpower issue that causes obesity and that the overwhelming majority of our patients are not at home eating chips, soda and Twinkies every night.

Zoe: 6:49

They are working their ass off.

Dr. Weiner: 6:50

They are working their ass off. You're right about it. They are working their ass off and it's not working, and so I think when you're out there looking at these comments, keep that in mind. Just because Chris said this does not make it even the slightest bit true. So, anyway, back to our story.

Dr. Weiner: 7:13

I think this approach to getting more access to GLP-1 medications, first of all, I'm not sure it's going to work. I'm not an attorney, but my suspicion is this is not going to go very far, especially against Cigna. Cigna is quite powerful and gigantic and has more lawyers working for it, and they're going to have no problem, I think, at the very least just delaying this for decades. So it goes nowhere, and Cigna has a very significant interest in being able to decide whether they're going to cover a certain medication or not, because if this happens for GLP-1 medications, it opens up the door to all these other medications as well, and so my concern about this approach is that it's not really targeting the fundamental issue with access to medications.

Dr. Weiner: 8:09

The fundamental issue, as we've talked about many times, is the cost of the drugs, and no matter if obesity is a disability or not, and that's an argument that others can have that I really don't have much of a stake in or honestly think is an important thing for us to be addressing.

Dr. Weiner: 8:28

The issue is that the meds are too expensive and we just cannot afford to treat everyone who deserves them, and so, until we reduce the cost, we're not going to make any headway, and so this lawsuit really is, in my mind, distracting.

Dr. Weiner: 8:44

It keeps us from getting to the root cause, that's preventing the patients who are out there who want and need and deserve GLP-1 medications from getting access to them, and we need to keep our eye focused on that, which is that the pressure should be applied to the pharma industry, to the pharmacy benefit managers, to the insurance companies, not in terms of granting coverage, but in terms of the added prices and costs that they implement in the administration and coverage of medications, and we need to work to reduce the cost. If GLP-1 medications cost $100 a month and were widely available, every insurance plan would cover them, and someday that will be a true statement, but it's not right now, and so we have to work toward that if we want to get coverage, not towards some kind of clever legal workaround that will end up not really making any headway.

Zoe: 9:37

Yeah, Maybe it'll help one person not millions yeah.

Dr. Weiner: 9:41

There's also kind of a catch-22 that's built into this, which is if you're determined disabled by the Social Security Administration, then you're typically going to be placed on Medicare, that's who covers patients with disability, and Medicare doesn't cover JLP1 medications for weight loss. So this argument doesn't have any legs and I don't think is something that's worthwhile, but it certainly brings up some interesting points.

Zoe: 10:08

Yeah, all right?

Dr. Weiner: 10:09

Well, let's move on to our patient story.

Zoe: 10:11

Well, we are really excited to welcome Nikki, our guest, on today's podcast, and Nikki is not a patient of ours, but she has a lot of really wonderful value to add, and so we're super excited to hear from you. Welcome.

Nikki: 10:25

Thank you so much. Thank you so much for having me. I'm happy to be here so.

Dr. Weiner: 11:20

Nikki, why don't you tell us a little bit about your story of bariatric surgery? Because you're like, you're the OG. You know you were one of the first people to have the surgery and I think it's really important for people to understand how far we've come with bariatric surgery.

Nikki: 11:35

Oh, we've come so far. I had surgery in April of 2001. I had an open RNY, which was generally what the only procedure my surgeon did back then.

Dr. Weiner: 11:47

Let me stop you for a second. Let me stop you and explain what an open RNY is to everybody out there. So they made an incision and that was the plan from the beginning. There was no laparoscopy. Five small incisions home the next day this was you know and they got at some point where they could make a relatively small incision. But this is a whole different ball game. So anyway, sorry to interrupt, but I I think it's important, that's okay.

Nikki: 12:15

That's a really important point it's very important because obviously the the recuperation is very different, you know. But I had surgery in April of 2001. I had struggled with my weight for probably 10 plus 15 years at that time and weight loss surgery was just basically becoming really, you know, big then and I started looking into it. I worked for an insurance company. I thought, well, I'm going to look into this, so I just went and I jumped into it and I had surgery and, boy, it threw me for a loop because it was like I was out there not knowing what I needed to do. I didn't have a lot of guidance with my nutrition. I didn't have a lot of guidance with the things that I was experiencing, such as like dumping that I thought was dumping at that time which turns out to be reactive hypoglycemia. We didn't know about that back then, and so there were so many things that I went through and things have changed. You know, just as we've progressed through these years, we've learned more and more about what is required. Our vitamin requirements have changed from 2001. We were told we could take Flintstones and we'd be good. Our calcium was take some Tums, you'll be good. That was it, and now I'm on a regimen of bariatric vitamins daily.

Nikki: 13:32

I started out at 340 pounds and I got down to 165. I maintained my weight. Yeah, I maintained my weight loss for about 13 years and I started to have regain when I went through some um medical issues with my parents and they both were diagnosed with cancer and so I started to experience some, and that just kind of snowballed and that I gained about 70 pounds back. And it was about two years ago. No, it was about a year and a half ago. I started just really focusing on trying to lose that weight. When COVID hit, I gained a little bit more too, of course. So about a year ago I decided that I needed to do something else and so I hopped on the GLP-1 and I dropped about 75 pounds. So I'm right now. I still got about 20 pounds to lose, but right now I'm like 179, 180. And I'm happy where I'm at because, given that I'm 23 years post-op, I feel like I'm still a successful RNY patient.

Zoe: 14:38

I think that's a really great example of how, even though your surgery was 23 years ago, the GLP-1 is such a powerful tool as combination therapy to really help you get that weight regain back off.

Nikki: 14:53

I can tell you that when I started those GLP ones, I felt like I was a new post-op again. I didn't have an appetite. It was back to those early days where I just I had to make myself eat, you know, and it was just really something that was like, okay, I can do this. You know, now I'm in the point where I'm like, okay, I got to maintain this. So it's definitely, um, something that I feel is a good option for the bariatric community, and I am hoping that we will see more of the insurance companies start to approve that for us, because I do think that it is something that's very important to help us, because I do feel like regain is kind of it's inevitable to some degree. I think we're all going to experience regain at some point in time and it just depends on to what degree it's going to be.

Zoe: 15:39

I was going to say and it's important also to help decrease the stigma around with that and know that it can be, you know, kind of part of the process. But there are tools and there is support and there is a community and providers all of the tools that one needs to really help get back that weight off but also not feeling shame around it.

Nikki: 16:03

Absolutely, that's. One thing that I really feel is very important is that we understand that we do need to have tools. Our surgeons get us through the process of having surgery, but we still need those tools through this lifelong journey to help us be successful. And that means if we've got to go through nutritional counseling, therapy for mental health, or if we need to have just a you know a medication that's going to help us, then so be it.

Dr. Weiner: 16:26

We need it, yeah they don't call it a journey for nothing, you know, and and I think they don't yeah, there's there's this kind of misconception that I see with a lot of patients who are going through surgery, and the truth is this expands in multiple areas, not just weight loss, but there's this idea that I've struggled with my weight. It's caused me so much dissatisfaction and unhappiness I'm going to have this surgery and then I'm going to be exonerated. I'll no longer have to deal with my weight. I'll no longer have to deal with my weight. I'll no longer have to worry about it. It will just be something that once happened to me and now I'm past it and unfortunately, that's not how it works. You had an excellent surgery, a gastric bypass. You had great weight loss for 13 years and then life happened Both parents getting cancer at the same time. It just probably threw your life in a total disarray, and that's what life does to us right what did john lennon say?

Dr. Weiner: 17:23

like life is what happens when you're busy making other plans. You know, and this is the stuff that happens to everybody at some point in their life and and it can distract you and and weight gain is often the side effect of just the stresses and unfortunate things that happen in our life, and that's when it's time to get back on the journey and kind of pull a new tool into the toolbox and add the nutrition in and do all the things that you've done. And I think every bariatric surgery patient has to understand that that's kind of how it goes.

Nikki: 17:55

It does, it does, that's very true, I mean. I used to tell everybody before life happens, divorce happens, hormones happen, Something's going to happen that's going to cause that weight gain. And one thing I used to hear people say is I've lost a hundred pounds forever. And I used to tell them you didn't. People that are on AA. When they drink, they can fall off the wagon, and we can too. It's not gone forever. You've got to be diligent because it can come back.

Dr. Weiner: 18:20

Yeah, yeah, it's that I'm never gaining it back, and I think that there's two components to that. The first is you never want to gain it back, I get it.

Zoe: 18:37

But the second, you believe that you can't that's when you, that's when the real danger comes in, absolutely. It also speaks to the power of that ongoing accountability and the community to keep checking in, like you mentioned with AA right, like that's a powerful community. That's ongoing accountability. And having a group, a powerful community such as the Bariatric community and all of the wonderful resources that you know, I know you offer and that we offer, is really kind of that piece of the puzzle that allows you to have those tools ongoing, since there is no end point.

Nikki: 19:11

Exactly. That's one of the reasons why I love this community, because I am so just settled into it that I know that when I'm around other people that are in this community, I'm held accountable. You know, I know that I'm going to be held accountable and this community is very tight knit. Our events that we have these you know that is part of going to these events. It's for you to be able to get education and support but also accountability. You to be able to get education and support but also accountability.

Nikki: 19:38

When you're there, you're going to network with people that you're going to basically walk away with lifelong friendships and they're going to help you through this process. You know, and I've met so many people at obesity help I have friends that I have worked with for 20 plus years never made them, met them face to face, but we have this camaraderie because we both had surgery and it's amazing. You know, I have a very good friend that I'm very close to, never met her face-to-face, but we have this relationship that's just very close because of our commonality with having had surgery around the same time. We're the original OGs of our company.

Dr. Weiner: 20:12

Yeah, talk to us a little bit about Obesity Help, what they do, what they offer, because one thing I love about bariatric surgery is the community. You know, and that's just what you just said. It's just that you know, and I think to some degree also, there's so much bias that still is out there against people who are suffering from obesity that that really brings people together who kind of have that shared experience of being discriminated against, and it kind of brings people together. So talk to us about what Obesity Help's mission is and what they're offering, because they really are a fantastic organization.

Nikki: 20:49

Yeah, so Obesity Help started back in 1998. We started out as a website that was built to be able to help individuals learn more about weight loss surgery and the surgeons that performed it. People didn't know a lot about it and so we launched this website. We had forums that people could get into. They could, you know, network with each other. It basically was the original Facebook, where people could get in there. They can meet with each other, talk. We had meetups and everything in different locations where people could get in there. They could meet with each other, talk, we had meetups and everything in different locations.

Nikki: 21:21

We evolved to adding bariatric-friendly products to our database and then we started adding plastic surgeons, because after you have bariatric surgery, you want to have reconstructive surgery because you've lost so much weight. So we evolved from that and we built a big community. We have about almost a million registered members all over the United States. We've been in operation for 20 plus years. I think we celebrated our 25th anniversary not too long ago. It has literally been a lifeline for a lot of people.

Nikki: 21:50

We have people that were on that website back when it first started and they still come back and they'll hop in and say you know I was here back when it launched. You know they're looking to see if they still have friends that are there. So this community is very tight knit and they don't seem to stray too far If they if people do tend to go, they're always coming back because they know where that support is at and that's what we tend to offer. Our mission is to provide education, support and assist people in learning about the resources that are available to them to help them through their journey, whether it's to lose weight naturally or if they want to lose weight through weight loss surgery, because there are other. There are options out there. Not everybody can qualify for surgery and not everybody wants surgery, but we're a resource for them either way and we try to bring all of that to the entire community. Whether they're going to have surgery or whether they're just going to lose the weight, we're there for them.

Dr. Weiner: 22:44

Talk to us about this conference. We're actually going, so tell us what should we expect. This is actually a pretty cool conference. We're excited about it.

Nikki: 22:52

Yeah, we're excited to have you. So what we've got this year is our Bariatric Connect 2024 National Conference. This conference is going to be held in Newport Beach, california, on September 20th and 21st. I'll slum it there for a little bit.

Nikki: 23:12

This is a two-day conference and it is two days that are filled with dynamic speakers. Those speakers are going to be talking about anything from nutrition to mental health issues, whether it's dealing with emotional eating or even body image. We've had individuals that have been struggling with body image post-bariatric. So we have a lot of great speakers that are scheduled to speak and we have that. Two full days that are going to be there, along with a vendor hall, and then on Friday night, after our very first day, we're going to have a costume meet and greet. That costume meet and greet is going to be sponsored by Total Lipidema Care. And then, on Saturday night, after our full day of sessions, we're going to have the fashion show and after party, and the fashion show allows individuals to, just, you know, get out there and celebrate their weight loss. They get to walk the runway, they get to dress up how they want, whether it's in a cocktail gown, whether it's a ball gown, whether it's a bikini. They get out there and they just, you know, celebrate that weight loss. And that, um, fashion show and after party is going to be sponsored by premier protein. So, in addition to our two Platinums, we have Dr Weiner, who is also going to be sponsoring, as a gold, a Pound. Of Cure is going to be a gold sponsor, so he'll have a session and you'll be part of our fireside chat, too, on Saturday. We're excited about that.

Nikki: 24:41

The best thing that our attendees love is number one. They walk away from this event with a lot of education and support. We talked about how close knit this community is. We have people that come all over. We have people that come from Canada to this event every year and they come every year and they get to meet up with their friends that they met, like the previous year. So when you come, you guys are going to walk away with just really getting to see a really close knit community like you already know exists, but you're going to get to see that from all over the United States that these people convert, you know, converging into one location, just really celebrating two days of all of their success and also their ability to just kind of, you know, maintain that that need to add the extra tools to their toolbox to make them success and have that long-term success that they need.

Dr. Weiner: 25:29

Yeah, for sure. I mean, I love the idea. What you're doing is you're providing the two key components for success after surgery, in my opinion, which is education and support. People need the right information. They need it presented in a very plain fashion like, hey, here's the good and the bad. I mean, everybody wants to lose weight. These surgeries allow you to lose 100 plus pounds. For most people. That's amazing. But there's other things, too, that go along with them, and so you've got to know all about them.

Dr. Weiner: 25:58

You've got to know about how your relationship with alcohol is going to change after surgery. You've got to know about risks of weight regain, possibility of using GLP-1 medications. And then, once you go through it, man, you need a couple friends because it's a crazy wild ride, and you need someone else who's taken that ride before to be able to share that experience, and someone else who understands. You know the good and the bad about these surgeries, and so obesity help really, really demonstrates the best of both of those by providing the education and the support as well. So if someone out there is interested in signing up for this conference or attending, give us some information. How much does it cost? Are there scholarship options? How do you sign up? How's that work?

Nikki: 26:41

So we do have scholarship options and I um those scholarship options can be found on obesityhelpcom and if you go and look for scholarships, it's going to be under our articles and you'll see a blog that will have a link to apply. Currently, our tickets are on sale for $120. However, we do have a pound of cure code that we're going to be providing to your patients and anybody that's listening, where they can get $25 off and the way that they can get that. There is a link that I've provided to your team so that they can share that, but that they can use that code and get that. We do have a block of rooms also that will be going off around August 25th. So if you're interested in going, make sure you get your ticket and get that block of room the room scheduled during that block, because that would be your best bet. But as far as scholarships go, if you guys need information, they can also email me at Nikki H at obesity helpcom and I can direct them where they can apply.

Zoe: 27:37

Yeah, and September and we'll put those links and everything in the in the show notes as well. So your email address and that kind of thing.

Nikki: 27:44

Right, and it's September 20th and 21st. Okay, september 20th and 21st.

Dr. Weiner: 27:48

Okay, september 20th and 21st, all right. Well, nikki, it was great connecting with you. I love your story. I think for people out there, I think a great take home message is here. You are 23 years after your surgery and have regained only 10 pounds and are still about 160, 170 pounds down from your highest right. Yeah, and I think that's one of the most amazing things about this surgery is that you know, with the right approach, the education, the support, the medications, the surgery, you can get that lifelong weight loss. That is absolutely possible. That's our mission and our practice for all of our patients.

Nikki: 28:28

Having the right tools in your toolbox are the ideal match, and that's where you guys are coming in, so love it. We hope to see more of you there at the event this year too. So thank you so much for having me All right.

Dr. Weiner: 28:40

What do you have for us on the nutrition front today, Zoe?

Zoe: 28:42

All right, so I wanted to talk a little bit about reading the nutrition facts label. It can be confusing.

Sierra: 28:50

To me.

Zoe: 28:51

Yeah, there's a lot to look at yeah size and the font like the size of the fonts and that sort of thing and added a couple lines on the Nutrition Facts label, which I think are all very meaningful and significant changes. However, it can actually increase the confusion, as I've noticed. I just had to go run and grab an example, because I don't know about you, but I'm a I'm a visual person, so I like to look at the visuals, but anyway. So the change of the nutrition facts label made some of the things easier to read. However, I find that it can make it more confusing, because if you're looking at this new nutrition facts label, what's the first thing that you? Your eyes go to? Calories, I don't care, I mean, you know.

Zoe: 29:49

Kind of kind of, I don't care but the very first thing that I always, always, always recommend looking at on a nutrition facts label is Fiber. Serving size.

Dr. Weiner: 30:02

Serving size.

Zoe: 30:03

If you don't know the serving size, the volume of food, the quantity, the portion that it's talking about, none of the other numbers mean a gosh darn thing. They're completely arbitrary, right? Are we talking about three quarters of a cup or are we talking about the entire freaking thing of yogurt? Yeah, right, so, yeah. So first, yeah, sure, if we want to care about calories, we can care about calories after we know the serving size, right?

Zoe: 30:29

And then that's when we can go into the protein and the fiber and then, specifically for what I wanted to talk about, line that breaks it out into added sugar. So we've got total sugar, which is naturally occurring sugar, and added sugar. And then that line of added sugar at the bottom is what we care about, because the naturally occurring sugar. We know that there's benefits in that and I dig into all of that in the All About Sugar support group. So if you're interested in learning more about that, then join me there. But ultimately we want that added sugar line to be as close to zero as much as possible, right, right. But moral of today's story is always start at the serving size.

Dr. Weiner: 31:21

I like that. So things like apple juice. There's tons of sugar in apple juice 25, 30, even more grams of sugar. But they claim it's no added sugar because they've extracted the good stuff, the fiber. Because for us if you're going to have the sugar, you got to have the fiber and the phytonutrients, all the other good stuff too, and so if you extract all that stuff it doesn't count as added sugar.

Zoe: 31:43

It still spikes your blood glucose.

Dr. Weiner: 31:45

But it's just as if you added the sugar directly. Yeah, and I think that's another important point, and really the food manufacturers, they're the ones who designed this label scam so that they can come up with ways that make things like apple juice appear healthier than Coca-Cola and you could argue apple juice is a little bit healthier than Coca-Cola, but it's certainly going to both be on that side of the spectrum where we don't want to drink very much of either of those. Right, and I think that it's important that we all understand that the big food, they have some influence into this label design, and so this did not come out of the dieticians at the FDA who said let's come up with the most transparent, obvious way that we can communicate the health of food to people. In the United States, there was a lot of influence from big food in creating these labels, and so it may not be quite as obvious and quite as useful as it could be Maybe meant to be confusing.

Dr. Weiner: 32:50

I bet if I put you in a room for an hour and said, okay, drop a new label, I bet you'd come up with something better than what we've got right now.

Zoe: 32:56

All right. So what do we have for economics of obesity today?

Dr. Weiner: 33:00

So I think this is kind of a follow-up to this conversation we just had about the lawsuit against Cigna that they should be covering GLP-1 medications. And I think this is the first thing that I just mentioned is that we got to figure out what the cost of the medication is. And the truth is there are medications out there like there's hepatitis drugs and other medications that are far more expensive than GLP-1s, but they're covered and a lot of the calculation that's done, unfortunately, is what's the cost of the illness and what's the cost of the medication and is it cost effective? And I think if we found that GLP-1 medications reduced all other healthcare costs by more than the cost of the medication, we'd see a lot more coverage.

Zoe: 33:47

I feel like we are seeing that. No, with the diabetes and the heart disease and all these other things fertility.

Dr. Weiner: 33:55

So stay tuned, because the answer is no, and that's really the question that I'm going to answer today. So the first thing is the question is what's the cost of being overweight, being obese? And we don't know. There's been a lot of studies that have been done to look at this, but there's a lot of different ways you can do it and a lot of different assumptions you can make, so there's quite a bit of variability for the answers. The other thing is it's different in different countries, right.

Dr. Weiner: 34:21

So having a heart attack in the United States is a lot more expensive than having a heart attack in France, and so when we're looking at the cost, there's a lot of different costs that go into it. There's, first of all, there's the medical costs, right Heart attacks, strokes, diabetes, all of these things, then the cost of treating them, and if we were to be able to treat your obesity, that a lot of those medical costs would decrease, not go away. They don't go away, they just decrease, and so we can only get that decrease. The second is disability, so loss of somebody who's able to work, and then, especially in the United States, we have disability payments that come, and so there's a cost there, and we know that patients with obesity have a much higher rate of disability than patients at a normal weight, and so we see disability, we see missed work and lost productivity, and so there's also early mortality. So there's all of these costs and these are costs to society that come from people being overweight or obese, and so they've done a lot of studies.

Dr. Weiner: 35:23

The first thing is let's look at the cost of some of the treatments, right? So the cost of bariatric surgery, which is covered by about 95% of insurance policies, is somewhere between $20,000 to $30,000. And the truth is, at this point, serious complications, the half a million dollar ICU stay those were more common in the past, but really we've eliminated those. I'm not even sure where the ICU is in our hospital and we just never have patients spending time in there. So it's about $20,000 to $30,000. And that in general, especially for gastric bypass, results in lifelong weight loss, and so all of a sudden that's not a huge amount of money if we're going to be able to save some money on these costs, and that explains why we see so much coverage for bariatric surgery.

Dr. Weiner: 36:09

We look at the cost of GLP-1 medications it's about $15,000 a year, and so year after year after year, that adds up very, very quickly. So if you look through all these studies and again, this is subject to much debate, so please don't take this as me stating this as fact but if you put all these studies together, we see that the cost of clinically significant obesity BMI over 40 with medical comorbidities, is about $7,000 a year. So the medications are twice as expensive as it costs society for people to be obese. When we have 40% of our population is obese, we're not going to get anywhere. And so what we're not going to get anywhere, and so what we're going to see is what we see.

Dr. Weiner: 36:56

We see that higher compensated employees, people with larger salaries, tend to have far more coverage options for GLP-1 medications, and it's, of course, because if you lose a week of work and you're making half a million dollars a year, that costs a company a lot more than if you miss a week of work and you're making $20 an hour, and so this is also something very unfair but we brought this up many times is that these medications are being used by patients, are much more commonly used by people with means than people without, and so we need to bring the cost of these medications down to at least $7,000 a year. So cut the price in half. That's a lot. This is actually. $7,000 a year is less than these medications cost in a lot of other countries, and so it is possible.

Dr. Weiner: 37:46

But until we start to see meds in the range of $200, $300, $400 a month as the total cost, we're probably not going to get very far with seeing widespread coverage. So I think that's the important question is what is the cost of being overweight and what is the cost of the medications? And until it becomes economically viable, we're not going to see the widespread coverage that we want, despite lawsuits against Cigna and all these other mechanisms that we're going to get. We're getting a ton of these questions lately. Keep them coming. I love reading them and we're doing our best to get to as many of them as possible, but keep them coming. You have any advice on the gallbladder?

Sierra: 38:33

I've found out I have gallstones and sludge. Is there anything I can do to prevent me from having my gallbladder removed?

Dr. Weiner: 38:55

Okay. So I'm going to talk about this in relationship to bariatric surgery, and I get this question minimum once a week from my patients. So there still remains this assumption that you should have your gallbladder removed at the same time as your bariatric surgery. And a lot of this comes from the fact that when we first started doing bariatric surgery we did it open through incision, and this incision made it quite easy to just take out the gallbladder while you're in there, and also at the time we weren't really skilled with laparoscopy. Now if someone's had a major abdominal surgery, I can still usually take out their gallbladder laparoscopically. 20 years ago I don't know if that's as true of a statement, because scar tissue makes everything a little bit tougher. So in the past when surgeries were done open, it was pretty routine to take out your gallbladder with the assumption that we don't want to have to put someone through a big open incision, open surgery down. You know, a year down the road, when we can just take it out at the same time With laparoscopy, it doesn't line up quite so nicely.

Dr. Weiner: 39:58

The first thing is is when you do laparoscopy there's kind of a directionality to it, so you kind of point these trochars or places where we put our instruments, you kind of point them in one direction or another. You don't have complete control over the entire abdomen and so when we do this surgery a gastric bypass, a sleeve, any bariatric surgery we tend to be pointed up to the left upper side of your abdomen. That's kind of where the majority of that surgery is done. The gallbladder is on the right, so it's the opposite direction, so it just doesn't line up. The second thing is that your complication rate, if you do a concomitant, meaning simultaneous removal of the gallbladder at the same time as bariatric surgery, doubles the complication rate and so that in general is discouraged. And so there's really I don't know of any surgeons that are routinely taking out the gallbladder. I do everything I possibly can to not take it out at the same time of surgery.

Dr. Weiner: 40:51

Now let's say you develop gallstones, what can be done to reduce your need to have your gallbladder out? The honest answer is probably nothing. Once you have gallstones and I think especially if you have had a gastric bypass, if you have even minimally symptomatic gallstones and I think especially if you have had a gastric bypass, if you have even minimally simple symptomatic gallstones, you should have your gallbladder removed, and in general, people tolerate the surgery quite well without a lot of long-term issues. I think if you don't want to have your gallbladder removed and are trying to prevent it, there is a medication called ursodiol and you can take it. And there you.

Dr. Weiner: 41:24

There are some practices that routinely prescribe ursodial after surgery to help reduce the risk of forming gallstones. The big problem with that is, as soon as you stop taking the ursodial, then you're prone to the development of gallstones, and so you're just kind of kicking the can down the road and putting off the inevitable, and most patients do not wanna take this medication for the remainder of their life in order to prevent gallstones. So the truth of the matter is, when it comes to your gallbladder, I think it's not the worst thing in the world to have your gallbladder removed. Most patients do quite well with it, and some of the complications that you can see in my recent trip to Guatemala would certainly support this can. Having a gallbladder that's causing trouble is pretty rough, and getting it out can actually improve your lifestyle quite a bit. So there's not a ton that's there, but I also don't think it's something that you should be afraid of. Sierra, what do we got for our next question?

Sierra: 42:21

Okay, this question is from YouTube. What to eat after bariatric surgery 2024. What about oats and almond milk?

Zoe: 42:29

So I think we're talking about making, like an overnight oats sort of situation. Yeah, me too. My main thing here is making sure that you have protein in that overnight oats, so I always like making mine with Greek yogurt. Sometimes we'll add some protein powder. Make sure you get some fruit in there. Well, depending on how far you are post-op right about having those whole foods.

Dr. Weiner: 42:51

I was going to say at what stage are people able to eat this? Is this yogurt, cottage cheese and applesauce kind of the first stage? How do people tolerate this? Because it's always confusing. You think somebody like eggs. Scrambled eggs are soft, but they're like the hardest thing to eat. Where does overnight oats fall into that?

Zoe: 43:11

I generally like to wait a little bit longer, especially because oats, although they are a healthy carbohydrate, we still don't want to be filling up on oats and kind of monopolizing that room in your stomach and not able to get in your protein and your fluids. So it's kind of balancing it. That's why I would really recommend to make sure you're getting some protein in there with it and then, if you're after that all of your food reintroduction phase and you're making overnight oats, make sure you get some fruit in there. Or my favorite way to make overnight oats is actually with veggies. I know, I know Carrot cake overnight oats and zucchini bread overnight oats. I'll have to share those recipes on another episode. My main thing here too, with the almond milk make sure it has zero added sugar, like what we talked about looking for in the Nutrition Facts Label Reading segment of the podcast.

Dr. Weiner: 44:04

Yeah yeah, there's a lot of sweetened oat milk, almond milk out there it's very easy to just oh, this one's on sale.

Zoe: 44:10

I'm just going to grab that one and not know what you're getting and the labels look like identical, it's so easy to buy the wrong one.

Dr. Weiner: 44:17

I mean, we go through a lot of almond and oat milk in our house and I swear it's like every six weeks we're like, oh, we bought this sugary stuff you know. All right, sierra. What's our last question?

Sierra: 44:29

Okay, this one is from Mackenzie. It came in by email. I'm not sure if this has been done, but what would you think if a patient wanted to take a JLP1 medication prior to a gastric sleeve or gastric bypass to lose the most amount of total weight possible?

Dr. Weiner: 44:44

So this is a great question and also, I think you know, when I see these questions, I feel like, all right, we're making a difference, because we've made a big point in the past about preoperative weight loss, driving additional weight loss after surgery. So the question is does GLP-1 driven preoperative weight loss have that same effect? And my thought is no, it does not. And the reason is and again I think it depends on which surgery you're having. If you're having a gastric sleeve, we've talked about how it's very likely that after a gastric sleeve, that you'll also need to supplement with GLP-1 medication at some point in the future. And so if it's before a sleeve and your plan is to use the GLP-1 medication after surgery, I think that that is reasonable.

Dr. Weiner: 45:31

I think if you're opting for a bypass because you believe that it won't require you to take the GLP-1 meds and your long-term goal is to not take GLP-1 meds, I don't see much role in doing it before surgery. I don't know that it's going to drive additional weight loss because you're going to stop the GLP-1. So it's like when you have surgery you're going to be like pushing down with one foot on the gas and one foot on the brake. The surgery is going to be the gas, but stopping the GLP-1 is going to be the brake Zoe. Before surgery we really work with our patients to optimize nutrition, and that is my thought on where your energy and effort should go to drive weight loss. Before surgery what are you doing with our patients before surgery? Kind of preparing them? Of course, the education about what they're going to do after surgery. But you're in that two, four, six-month waiting period for surgery. What are you having our patients do? What are you instructing them on?

Zoe: 46:23

Yeah, that's really great, because this is actually a really valuable period of time to establish new habits that will help them be successful after surgery. I always like to have the analogy of you don't want to try to change everything all at once because that makes you feel overwhelmed. So if we can start chipping it away at some of these habits that will help them be more successful after surgery, then that's time well used. And specifically to drive, you know, trying to maximize weight loss before surgery, let's do the metabolic reset diet. Let's do that for as long as possible while working on some of these other habits, so that you will be going into surgery in a really great spot and then, after your surgery, of course, you can then keep up some of those habits that you've built beforehand.

Dr. Weiner: 47:11

Yeah, I think you also do a great job of kind of challenging patients a little bit. There's a lot of people go into this and I'm not a veggie person, I'm not a fruit person, like they have these preconceived notions. This is just not who I am, this is not something I do, and I think you do a really nice job of kind of gently challenging them to become a veggie person and to become a fruit person, to open your mind to the idea that maybe you're capable of more change than you've given yourself credit for. And I think that's also really important before surgeries. Take these preconceived ideas that you've had and make sure that you are challenging yourself and putting yourself in the best position to have that great diet afterward. And I think Sierra, our office manager, would be very upset if I also didn't mention that you have to be careful taking GLP-1 meds before surgery, because the criteria of your BMI and most insurance companies still use BMI over 40 without a comorbid condition or BMI over 35 with a comorbid condition it is possible to disqualify yourself for surgery if you use the medications and lose too much weight beforehand, and so that's also something to keep in mind as well. All right, I think that wraps us up for another episode 31 in the books.

Dr. Weiner: 48:27

This podcast is produced by Sierra Miller and Rhiannon Griffin. We could not do this without them, for certain. In fact, we couldn't do most of the things that we do without those two huh.

Dr. Weiner: 48:39

And the editing is done by Autogrow, and if you found this helpful, please share, review. Do all the things that you normally do with the podcast or social media to help get the word out there. Our goal is to keep people like Chris quiet and to put some content like this that really supports those who are out there suffering with obesity, so that they can hear some positive things and get some advice that is science-backed and actually productive to helping you meet your weight loss goals.

Zoe: 49:09

See you next time See you next time.